The Final Board of Inquiry – Commander Richard R.

Paton, USCGR (Ret)

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 The Final Board of Inquiry
A Cold Case Investigation into the Loss of the Steamship Titanic
By Commander Richard R. Paton, USCGR (Ret)

A new review of the testimony, photographs, plans, eyewitness accounts, facts and circumstances surrounding
the loss of the steamship Titanic. The likely result, if the new findings of fact were presented to a
Marine Board of Inquiry convened today, could be quite different.

Introduction and Charge to the Board
One hundred years ago, in the cold, dark, early morning hours
of 15 April 1912, the new and magnificent White Star liner
RMS Titanic sank after colliding with an iceberg,
approximately 365 nautical miles east-northeast of the
Newfoundland coast. The ship, en route to New York on her
maiden voyage, was at the time the largest passenger liner in
the world, but certainly not the fastest. Although touted as
nearly unsinkable by many, the great ship foundered some two
hours and forty minutes after striking an iceberg, sending her
approximately two and a half miles down to the bottom of the
North Atlantic. The loss of life was horrific and, for many,
totally unnecessary and was the greatest maritime disaster of
the time. No one was ever held accountable for the negligence,
gross negligence, or criminal acts that resulted in the needless
deaths of this tragedy. Despite two separate inquiries
conducted in America and Great Britain shortly after the
disaster, no conclusive charges or specifications were brought
or criminal investigations recommended.
The American inquiry was well-intentioned but ill-
equipped to ask the right questions. Nonetheless, several
important facts were uncovered although not acted upon. U.S.
jurisdiction, which might have been applied, was not. The
British inquiry was strictly and conveniently limited in scope to
answering only 26 carefully selected questions handed down
by the British Board of Trade. The composition of the British
inquiry might today be considered a rather obvious conflict of
interest, but in 1912, the Edwardian England class system still
prevailed. Even at the time, however, the British inquiry was
considered a whitewash. In essence the British Board of Trade
was to a great extent investigating the White Star Line and the
British Board of Trade itself, along with its inspectors and
regulations, with the unsurprising result being that the British
Board of Trade found neither party at fault.

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 In the United States in 1912, the modern-day U.S.
Coast Guard had not yet been created. It’s predecessor service,
the United States Revenue Cutter Service, and the earlier
Revenue Marine, while primarily empowered to enforce
customs laws, lacked the authority to investigate marine
casualties. Neither the U.S. Board of Steamboat Inspectors,
created by Congress in 1838 for the enforcement of vessel
safety standards, nor the later Bureau of Marine Inspection and
Navigation played any prominent role in the American inquiry
headed by U.S. Senator William Alden Smith of Michigan. The
American inquiry examined 82 witnesses, of which 53 were
British subjects or residing in Great Britain and 29 were
citizens or residents of the United States.
No recommendations or actions were taken by either
boards of inquiry to commence suspension or revocation
proceedings against the licenses, certificates or seaman's
documents of any of the officers or crew of the Titanic or to
initiate action that would result in civil penalties against the
owners or to recommend criminal investigations and
indictments against certain of the officers, crew and at least
two passengers for criminal action and inaction resulting in
hundreds of counts of involuntary manslaughter. U.S.
admiralty jurisdiction, which might have been exercised and
applied as the result of U.S. corporate ownership and control of
White Star, was never brought to bear despite the number of
U.S. citizens killed as a result of the actions and inactions,
errors and omissions of the crew and the ship’s operators,
White Star and, ultimately, the U.S. owners. Justice was never
attained for the hundreds who died horrific and painful deaths
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while within sight and sound of nearby lifeboats, only partially
filled, which could have rescued so many.
This article cannot replicate the 3,200-plus pages of
testimony from the British inquiry, officially the “Wreck
Commissioners’ Court,” held at Scottish Hall, London, 2 May
to 30 July 1912, or the 1,500-plus pages of testimony obtained
from the American inquiry, officially the “Hearings Before a
Subcommittee of the Committee on Commerce, United States
Senate,” held at the Waldorf Astoria in New York and the
Russell Senate Office Building in Washington, DC, 19 April to
28 May 1912. The intent of this research was to take an
unbiased and fresh look at the evidence in various documents,
official testimony, reports, original photographic evidence,
recalculations of reported dead reckoning and celestial
navigation position reports, radio telegraphy messages,
documented statements made by survivors and crew members,
newspaper articles of the day, manifests, immigration
documents, corporate governance, and new evidence obtained
from actual audio recordings made several years later by
Titanic surviving officers and passengers.
My interest in the inquiries was prompted by my
background in marine engineering as a former Merchant
Marine Officer, active-duty Coast Guard Marine Inspector and
Investigating Officer and long-standing Coast Guard Reserve
Officer, now retired. Later, as a corporate risk manager and
insurance executive, I was intrigued by the Titanic’s strange
chain of corporate ownership, governance and control through
now non-existent and illegal business Special Trust vehicles.
These were common at the turn of the 20th century as a
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favorite business form of organization and were used to
constrain free trade and monopolize industrial sectors including
transatlantic shipping, steel production and railroads during the
period of the “robber barons.”
These various areas of interest converged when I
looked at the rather dark case of the Titanic. This new
investigation considers the causes of the sinking and the great
number of deaths, more than necessary even given the
inadequacy of the ship’s lifeboat capacity. New light is shed on
the unsung heroes of the disaster, including the engineering
officers and crew, many of whom gave their lives to delay the
sinking. At the same time, it is not my intention to diminish the
memories of the dead, passengers or crew, who made
dreadfully bad decisions in horrific situations.
Someone must speak for the dead. I cast no indictments
or allegations but merely hope to shine light upon the
horrifying events of that fateful evening. I will present the
evidence to the reader, who will serve as the Final Board of
Inquiry into the circumstances surrounding the loss of the
Titanic and the deaths of approximately 1,500 people. In this
context I will be serving as the notional Investigating Officer of
the Board on which you the reader are now to serve. You must
weigh the facts and be the judge, knowing that those
individuals cast in unfavorable light are not here to defend
themselves. It is my hope that the Final Board, after its due
diligence, dispatch and judicious deliberation, will reach its
own thoughtful conclusions and that the decision shall be both
just and compassionate.
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
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Scope of the Investigation
The investigating officer will present to the Final Board
information and evidence relevant to the seaworthiness of the
vessel and its crew, the ship’s ownership, management and
control, occurrences both prior to and after the collision, the
exercise of command, actions and inactions of the officers and
crew, ship’s communications, navigation and seamanship,
technical details of the vessel and its safety appurtenances,
evacuation of passengers and crew, the failure in most cases of
those in lifeboats with surplus capacity to rescue or attempt to
rescue those persons in the water, drowning within sight and
sound, the manning and equipment of lifeboats, inspections by
the Board of Trade, response of nearby vessels, and other
pertinent facts of the case.
This investigation will not address the issues
surrounding the failure of other vessels to provide timely
assistance to a vessel in distress with urgency and dispatch. We
would need to know the facts, circumstances and situations
arising out of the conduct of the SS Mount Temple and the SS
Californian and their Masters to understand their response to
Titanic’s distress messages, which is beyond the scope of this
investigation.
The Investigating Officer will present the following
items of interest and evidence to the Final Board:
1. A timeline of 1911–1912 historic events leading up to the
Titanic disaster to further appreciate the technological
advances and societal values of the time
2. Technical background on the design and construction of the
Olympic-class ships
3. The operation of business trusts, anti-trust laws and the
robber barons
4. What was the International Mercantile Marine Company
and who really controlled the White Star Line
5. Ownership, management and control of the Titanic
6. Issues of jurisdiction as the result of ownership and control
vs. registration
7. Propulsion systems, auxiliary systems, horsepower,
displacement, registered gross tonnage, watertight
subdivision and other technical data relevant to the
investigation
8. Initial designs for lifeboat capacity and the myth of speed
records
9. Sea trials, Board of Trade inspections, certificates of
inspection and seaworthiness
10. Last minute crew changes and the mysterious case of the
lookout’s binoculars
11. Communication systems, failures, operations and their
crucial role aboard Titanic
12. The voyage – weather, sea conditions and ice warnings
13. The collision
14. Navigation errors, true positions and location of the wreck
itself
15. The evacuation of passengers and crew
16. The sequence of events (and non-events) aboard Titanic
prior to her collision and subsequent sinking
17. The survivors and those drowning nearby
18. The truth behind the famous missing Masaba message
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19. The application of causa causae est causa causorum in the
case of the Titanic disaster1
20. Events after the collision and those during and after
evacuation of the ship that led to greater loss of life
21. Aftermath and rescue
22. Findings of fact, charges and specifications and
recommendations of the Final Board for adjudicatory
proceedings and criminal proceedings regarding certain
officers, crew and passengers
23. Epilogue
The Titanic, the Gilded Age and the Advent
of Technology
In order to better understand and appreciate the tenor of the
times, the state of the art in technology, the newly introduced
use of radiotelegraphy in world and marine communication,
and the age when mechanical technology was near its zenith,
we should take a serious look back in time to a period in
history often referred to as the Gilded Age, when the excesses
of wealth, style, design, comfort and luxury were at a peak. By
looking back I hope the reader will retreat to a slower time
period, when Titanic represented the very latest in
technological advancement, the heavily gilded design of the
Beaux Arts period, and the conspicuous consumption that was
a reality of the age. A look back to the dawn of air travel and a
time when a class-ranked society prevailed in England and to a
lesser degree in the United States. The following is a brief
review of world events in the early 1900s and the first shadows
of the global preparations for the First World War. This is the
world into which the Titanic was launched and in which its
passengers and victims lived and died.
1911
The first experiments with bombing from an aircraft were
conducted in San Francisco and the first photograph was taken
from an airplane in San Diego. The USS Pennsylvania
conducted the first landing of an aircraft on a ship, and the first
nonstop flight from Paris to London was completed in three
hours and 56 minutes.
The United States Supreme Court acted to dissolve the
Standard Oil Company under the newly enacted Sherman Anti-
Trust Act. The New York City Public Library Building opened
and the RMS Titanic was launched at the Harland & Wolff
shipyards on 31 May 1911. Crisco was introduced in the
United States by Procter and Gamble. New technology made
the headlines as the first Marconi radio message from Italy was
received in New York City. The first group insurance policy
was issued.
In England, King George V was crowned and Lloyd George
warned Germany in a speech at Mansion House. Prime
Minister Asquith held secret meetings about a potential war
with Germany while the British Army prepared. In France the
Mona Lisa was stolen from the Louvre and Madame Curie
received her second Nobel Prize.
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1912
In England, Winston Churchill announced that the Royal Navy
would be enlarged and the British War Staff is established.
Scott’s Antarctic expedition reached the South Pole only to
discover that Amundsen had arrived there first. Coal miners
throughout England went on strike and the Titanic commenced
her sea trials in Belfast Lough on 2 April 1912. The Royal Air
Force was formed and England informed Germany that it
would aid France in the event of attack by Germany. The
clouds of war were already forming.
In other maritime news three unrelated sea disasters
took place. The SS Kichemuru sank in a violent storm off the
coast of Japan with a loss of 1,000 lives, the Spanish SS
Principe de Asturias sank with 500 dead, and two steamships
collided on the Nile resulting in 200 deaths. The Titanic left
Southampton for Cherbourg on 10 April and later commenced
her maiden transatlantic voyage from Queenstown (now Cobb),
Ireland, to New York. The Titanic subsequently sank on 15
April at 0227, approximately 365 nautical miles off the
Newfoundland coast, with great loss of life.
In the United States the first lady, Mrs. Taft, planted the
first cherry tree in Washington, D.C. The Dixie Cup was
invented and U.S. Marines invaded Nicaragua and re-invaded
Cuba. The Beverly Hills Hotel opened, and Senator Smith held
a Senate Commerce Committee Inquiry into the loss of the
Titanic.
This is the backdrop against which the world, while still
at peace, witnessed the worst maritime disaster it had ever
experienced. It was a loss that was suffered by not only
immigrants and middle-class professionals but by the elite of
high society and wealth on both sides of the Atlantic as well.
The Actual Ownership of Titanic and Case
for U.S. Jurisdiction
In an attempt to monopolize trade in the transatlantic shipping
business, J.P. Morgan established The International Mercantile
Marine Company in 1902, six months after he had bought the
White Star Line. As a steamship trust it would work to control
transatlantic competition in the shipping business, endeavor to
reduce shipping rates at selected ports, give kick-backs,
discounts or rebates to companies shipping their goods only
with the trust, refuse to carry the goods of companies dealing
with other shipping lines, and create special contracts with U.S.
railroads. It would strive to drive honest competitors out of
business or swallow them into the trust. IMM operated as a
corporate entity, holding company and trust.
The trust would operate in the following manner. The
corporate executives and the board would threaten and compel
shareholders of competing firms to surrender their shares of
stock to a board of trustees, who would then issue certificates
that would pay a dividend. The board of trustees would
exercise the voting rights representing these shares, placing
their own people on the board, appointing their own selectees
as officers of the corporation and wresting control of these
companies. They restrained trade and eliminated competition in
the process, thus creating a monopoly.
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
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IMM controlled the Fidelity Trust Company of
Philadelphia, Leyland Line, Dominion Line, Atlantic
Transportation Co, International Navigation Company, and
Oceanic Steam Navigation Company, who in turn owned the
White Star Line. IMM also had profit-sharing agreements with
Hamburg-America and North German Lloyd.
Other large trusts and industrial combines at this time
included U.S. Steel, American Tobacco and Standard Oil
Company. In 1890 Congress had enacted the Sherman Act (26
Stat. 209 (1890) as amended). The act applied to significant
restraints on commerce either foreign or domestic. It took time,
however, to investigate and prosecute trusts and to break them
up. In 1898 President McKinley appointed the U.S. Industrial
Commission to break up the trusts; this was later followed up
by President Theodore Roosevelt. The Clayton Anti-trust Act
wasn’t passed until 1914.
Notwithstanding that Titanic was owned by White Star
Line, registered in Great Britain with British officers and crew,
she was nonetheless an asset of a wholly-owned subsidiary of
the Oceanic Steam Navigation Company, which was owned by
International Navigation Company, Ltd., of England, which
was owned by J.P. Morgan’s IMM, an American corporation
organized under the laws of the State of New Jersey with J.P.
Morgan a principal and citizen of the United States. Thus, the
ship was in fact an American-owned vessel although operated
by a subsidiary domiciled in the United Kingdom.
A more modern statute, 18 USC 9:1 62 Stat 685,
defined the issue as follows: “The term vessel of the United
States, as used in this title, means a vessel belonging in whole
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or in part to the United States, or any citizen thereof, or any  Chief Designer for Stability, Damage Control,
corporation created by or under the laws of the United States, Drawings and Safety: Edward Wilding
or of any state, territory, district or possession thereof.”  Builder’s Number: 401
Regarding ownership and the rights of any sovereign nation to  Keel Laid: 31 March 1909
investigate and take action when some of its citizens are killed,  Shell Plate (side) Thickness: 1.0 inch
the United States would have had jurisdiction to not only hold  Launched: 31 May 1911
an inquiry, but to also initiate legal action against those  Delivered: 3 Feb 1912
responsible for the disaster and loss of life.
 Compartment Flooding: Designed to remain afloat with
any two flooded
RMS Titanic – Technical Data and  Mean Draft of Water: 34 feet
Specifications  Design Load Draft: 34 feet, 6 inches
Subject: RMS Titanic, British Registry, ON. 131428, Port of  Service Draft: 34 feet, 6 inches
Registry Liverpool, foundered on or about 0220 local time on  Tons per Inch Immersion: Unknown
15 April 1912 at or near position 41.46N lat, 50.14W long,  Freeboard: 30 feet, 4 inches
with loss of life.  Length: 882 feet, 6 inches3
 Vessel Name: RMS Titanic  Beam: 92 feet
 Vessel Official Number: 131428  Length to Beam Ratio: 9.59
 Country of Registry: United Kingdom  Block Coefficient: Unknown
 Official Port of Registry: Liverpool, England  Keel to Masthead: 240 feet
 Owners: Oceanic Steam Navigation Company, Ltd., 30  Height to Navigation Bridge: 104 feet
James St., Liverpool, England  Gross Tonnage: 46,328.574
 Class: Olympic  Displacement Tonnage: 66,0005
 Line: White Star/IMM  Cubic Meters: 131,109.48
 Builders: Harland and Wolff, Belfast, Ireland  Service Speed: 21 knots
 Shipyard Managing Director: Rt. Honorable Alexander  Max Speed: 23 knots
M. Carlisle  Flank Speed: 23.5 knots
 Design Department Managing Director: Thomas  Stopping Distance at Trials: 850 yards, three times ship
Andrews, Jr.2 length, under 0.5 nautical miles

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 Watertight Compartments: 16  Certificated Crew: 892
 Watertight Doors: 15  Certificated Passengers: 2,434
 Double Bottoms  Actual Persons on Board: 2,208 Inclusive of Crew8
 Screws (3): o The number of persons onboard at last port of departure is
uncertain, but believed to be 2,208.
o 3-bladed (Port and Starboard), 23 feet, 6 inches
in diameter  Estimated Crew Onboard: 892
o 4-bladed (Center), 16 feet, 6 inches in diameter  Estimated Passengers Onboard: 1,316
 Propulsion:  Communications: Wireless Radio Telegraphy, Marconi
o 2 triple expansion steam reciprocating engines Wireless Telegraph Co. Ltd.; Marconi Marine Wireless
(Port and Starboard) 5.0Kw, Synchronous Rotary Spark Discharger; 2
o 1 Parsons low-pressure steam turbine, no astern Operators; Ship’s call sign MGY
element (Center) 6 o Morse Lamp
 Horsepower: o Masthead Lamp
o Reciprocating Engines, 15,000 horsepower each o Ship’s Steam Whistle
o Turbine, 16,000 horsepower o Visual Day Signals
o Total: 46,000 horsepower o Distress Rockets
 Boilers (29):  Lifeboats:
o Type: Scotch Marine – Fire Tube o 14 Standard (cap 65 persons each)
o Steam Pressure: 215 psi o 2 Emergency Cutters (cap 40 persons each)
o 25 double-ended, 4 single-ended, 159 furnaces o 4 Englehardt Collapsibles (cap 47 persons each)
o 20 Boats Total (cap 1,178 persons)
 Fuel: Coal
 Percent Lifeboat Capacity to Maximum Certificated
 Stacks: Height 75 feet, 3 inches functional, 1-inch
Ship’s Capacity: 35%
dummy7 – Ventilation machinery
 Percent Lifeboat Capacity to Persons on Board at time
 Registration: British Board of Trade
of sinking: 53%
 Certificate of Inspection: Passenger Certificate,
Expiration Date: 2-04-13  Lifeboat Under Davits: 16
 Lifeboat Construction: Wood
 Certificated Capacity, Passengers and Crew: 3,326
Maximum  Life Jackets: 3,560
 Life Buoys: 48

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  Is the ship supplied with all life-saving appliances
required by the rules?
o Yes (Board of Trade Survey M23780, Number
403, dated 11 April 1912)
 Master: Edward John Smith
o Certificate: 160802 Grade: Extra Master
 First Mate: Henry Tingle Wilde
o Certificate: 027271 Grade: Extra Master
 Second Mate: William McMaster Murdock
o Certificate: 025480 Grade: Extra Master
 First Engineer: Joseph Bell
o Certificate: 19224 Grade: First Class
 Second Engineer: William E. Farquarharson
o Certificate: 32893 Grade: First Class
Deck Officer Qualifications
 Edward John Smith, Master
o Extra Master’s Certificate
 H. F. Wilde, Chief Officer
o Ordinary Master’s Certificate
 W. M. Murdoch, First Officer
o Ordinary Master’s Certificate
 C. H. Lightoller, Second Officer
o Extra Master’s Certificate
 H. J. Pitman, Third Officer
o Ordinary Master’s Certificate
 J. G. Boxhall, Fourth Officer
o Extra Master’s Certificate
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 H. G. Lowe, Fifth Officer
o Ordinary Master’s Certificate
 J. P. Moody, Sixth Officer
o Ordinary Master’s Certificate
Edward John Smith, Master – History of
Prior Incidents
Captain Smith began his seagoing career at age 13. He
obtained a Master’s Certificate at age 25 and joined White Star
Line in 1880. He obtained his first command in 1887 as Master
of the Celtic.
He was Master of the Republic in 1889 when the ship
ran aground off the Port of New York and remained aground
for several hours before being refloated. Three crewmen were
killed the same day in a boiler explosion. Just one year later he
ran aground again in another ship approaching Rio de Janeiro.
Captain Smith commanded several troop ships during
the Boer War and rose to the rank of Commander in the Royal
Naval Reserve, which allowed any merchant ship under his
command to fly the RNR Blue Ensign instead of the Red
Merchant Ensign, often called the Red Duster.
In 1899 the SS Germanic, another White Star liner with
Smith in command, capsized in New York Harbor as the result
of severe icing and the failure to remove the ice from the ship’s
structure. In 1901 the Majestic and in 1906 the Baltic
experienced serious fires while Smith was in command. In
1909, while in command of White Star’s flagship, Adriatic, he
again ran aground in Ambrose Channel, New York.
 In June 1911, while in command of Titanic’s sister ship
Olympic, Smith damaged and nearly crushed a tug while
berthing the giant liner in New York Harbor.
While Smith was in command of Olympic on 20
September 1911, in the Solent and passing around the east end
of the Isle of Wight at about 18 knots, Olympic collided with
HMS Hawke, a 7,250-ton Royal Navy Cruiser. The collision
resulted in substantial damage (a 40-foot gash in the starboard
side) to the Olympic. Both ships were afloat and made it back
to port, with Olympic having two flooded watertight
compartments and running on just one engine; the ship made it
back safely to Southampton for emergency repairs that took six
weeks. The Titanic had to be moved to accommodate her and On 10 April 1912, while departing its berth in
Titanic’s starboard propeller shaft and other components were Southampton under Smith’s command, Titanic had a near
removed to facilitate repairs to Olympic, which didn't return to collision with the liner New York. The Titanic passed two ships
service until 29 November 1911. near the end of the docks, turned to port and increased speed.
On 24 February 1912, while under Smith’s command, This maneuver created a suction force (the canal effect), which
Olympic struck an uncharted underwater obstruction while caused the New York to part its lines with her stern being
transiting eastbound near Georges Banks. This grounding carried out into the path of the Titanic. Quick action by nearby
resulted in the loss of a propeller blade, requiring a return to tugs avoided yet another collision.
Harland & Wolff for repairs, returning to service in March Captain Smith, known as the Millionaires’ Captain, was
1912. 62 years of age and was planning to retire upon reaching New
York, returning as a First Class passenger aboard Titanic. He is
missing and presumed dead as a result of the sinking of the
Titanic. He was 62 years of age.

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Joseph Bell – Chief Engineer
Joseph Bell received his apprenticeship at Robert Stephenson
and Company and entered the merchant navy in 1883, serving
aboard the ships of Lamport & Holt, Ltd. Bell joined the White
Star Line in 1885, serving aboard the Majestic, Britannic,
Teutonic, Ionic, Bovic and several other ships including the
Olympic. He was transferred from Olympic to Titanic. He
attained the rank of Chief Engineer at the age of 30. Bell’s 16-
year-old son, an apprentice at Harland & Wolff, joined his
father aboard the Titanic on its voyage from Belfast to
Southampton. Bell was admitted to the Institute of Marine
Engineers in 1891 and was also a member of the Royal Navy
Reserve. He was considered by the Institute of Marine
Engineers to be one of their most capable officers and was held
in high regard by his colleagues. Bell is missing and presumed
dead as a result of the sinking of the Titanic and was 51 years
of age. He left a widow and four children, the oldest age 16.
There are no known incidents reflecting upon his professional
career.
Design Issues
There were at least two major design issues that affected the
foundering of the Titanic and the number of persons who could
have been saved. The first was a design flaw in the transverse
watertight compartments, and the other was the flagrant
shortage of lifeboats or rafts capable of carrying the
Certificated Capacity of both passengers and crew, a number
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which was far greater than that actually onboard the Titanic the
night she went to the bottom.
In the first instance, the watertight bulkheads were not
carried to the strength deck nor were they fitted with watertight
hatches from deck to deck. This allowed water from one
flooded compartment to cascade over to the adjoining
compartment depending on the trim of the ship and to a lesser
degree the list.
The ship’s double bottoms did not extend up beyond
the turn of the bilge. The 15 transverse watertight bulkheads
created 16 watertight compartments that were carried up to F
Deck at both the bow and stern sections and to E Deck in the
middle two-thirds section of the hull. Titanic had eight major
decks, ranging from A Deck just below the open boat deck
down to G Deck. Below G Deck the engine spaces were
situated on the Orlop Deck closest to the keel and floor plates,
just above the double bottoms. The bulkheads were constructed
of one-inch steel and reinforced with steel frames. Titanic was
designed as a two-compartment ship, meaning she could
remain afloat with any two watertight compartments flooded.
Eyewitnesses reported six watertight compartments breached
as the result of the collision with the iceberg.
The number of lifeboats for Titanic and her sister
Olympic were grossly inadequate. British Board of Trade
regulations had been last updated in 1898 and were based on
cubic-foot capacity and GRT of the ship, with the maximum
being 10,000 tons. By 1912 shipbuilding and technology were
creating much larger ships such as the Cunard liners Lusitania
and Mauretania9 with GRTs of 31,938 and Olympic and
 Titanic with GRTs of 46,328. Titanic carried 20 boats and
actually exceeded the minimum number required with a
capacity of 11,327.9 cubic feet while the regulations at the time
required only 9,625 cubic feet. However, the Right Honorable
Alexander Carlisle, Managing Director of Harland & Wolff,
had presented two sets of plans to White Star, one showing 32
lifeboats and the other 64 lifeboats. These plans were rejected
by the owners of Titanic due to concerns that the additional
boats and davits would clutter the boat deck and ruin the views
of passengers strolling the upper deck. The 20 boats supplied to
Titanic (only 16 of which hung from Welin double-acting
davits) had a total capacity of 1,178 persons, equal to 35
percent of the 3,326 persons allowed by the Board of Trade’s
Certificate. Under the rules of this regulatory body, 2,148
people would be left standing at the rails of a sinking ship, an
error beyond comprehension and any modicum of common
sense. The important design issue here is that while the
builders did indeed recommend much greater lifeboat capacity,
the ship’s owners rejected those plans in favor of an
unobstructed view for passengers, and the British Board of
Trade stubbornly held onto its outdated regulations and
certified the Titanic notwithstanding this fatal design flaw.
There was no provision on Titanic to promptly notify
passengers of emergencies. While technology for sophisticated
public address systems did not exist in 1912, the use of electric
alarm bells did, and in fact bells were provided at the
watertight doors on the lower decks to warn of their closing.
No alarm was provided to alert passengers to go to their
lifeboat stations.

The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)

15
Sea Trials and Owners Acceptance
Titanic’s sea trials were originally scheduled to take place on 1
April 1912 but were delayed one day as the result of bad
weather. At 0600 on Tuesday 2 April, the Titanic moved under
her own power for the first time. After departing Belfast Lough
with a crew of only 120, sufficient to handle the ship on a short
voyage, Titanic conducted a series of sea trials in the Irish Sea.
She slowly built up her speed to 20 knots and then came to an
emergency stop, with the engines reversing full power, in 850
yards, or approximately three ship lengths. During timed speed
runs she averaged 18 knots. (It should be noted that the ship’s
centerline engine, the Parson’s Turbine, could not operate
astern.) All machinery and the steering gear were tested with
good result. One of the most important of the sea trials was a
full-speed turn, inscribing a circle with a diameter of about
3,850 feet. At a speed of 22 knots it would take the Titanic 0.4
nautical miles (800 yards, 2,400 feet) to make a 90-degree turn.
At 22 knots, the ship is traveling at 2,199.99 feet per minute.
In addition to the crew, two Marconi operators,10 John
George Phillips, senior operator, and Harold Bride, had been
brought aboard at Belfast by the Marconi Wireless Telegraph
Company to install the marine radio equipment on Titanic and
operate its radio room. The two were to man the ship’s radio 24
hours a day, standing six- hour watches. The Marconi
Company also supplied access to a network of Marconi land
stations. The radio equipment was delivered to Titanic in time
for its sea trials on 2 April, and it took the two operators the
remainder of the day to install, adjust and test it. On 3 April
test messages were transmitted to and received from Tenerife
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
16
in the Canary Islands, 2,000 miles distant, and Port Said, over
3,000 miles away. Titanic’s new call sign was MGY with the
M designating a Marconi Company station. The powerful 5.0
kilowatt, synchronous rotary spark discharger radio apparatus
aboard Titanic was far advanced compared to the common 1.5
kilowatt radio installations found on most merchant ships.
Radio communications at the time had a very limited range,
only about 250 miles during daylight hours. Titanic’s night
radio range exceeded 2,000 miles. There was heavy reliance on
messages being relayed by other ships. The Marconi radio
rooms were located on the boat deck just aft of the bridge and
the officers’ quarters. The radio rooms were in communication
with the purser’s office below by means of pneumatic tubes, in
which private messages written by passengers would be carried
to the radio room for transmission after the purser had collected
the appropriate fee. The rooms consisted of a small office,
adjoining sleeping area and a separate silent room,
soundproofed to house the noisy spark transmitters.
Francis Carruthers, the Board of Trade Surveyor, was
also aboard during trials, making his final inspection of the
ship and its lifeboat equipment and other required details. He
signed the ship’s Certificate of Seaworthiness, which was
required for the ship to carry passengers for hire. This is
noteworthy because later accounts by officers and other
survivors aboard the boats held that equipment and provisions,
including green lights, oars, axes, knives and other items, were
inadequate or absent entirely. After the trials the ship returned
to the Belfast Lough and moored for a short time to allow
shipyard workers, vendors, officials and others to return to
shore. Thomas Andrews represented the shipyard in the signing
and exchange of the necessary documents of acceptance with
Mr. Harold Sanderson, a director of the White Star Line.
Titanic departed Belfast shortly after 2000, conducting
additional tests during the 570-mile transit to the White Star
dock at Berth 44 in Southampton. En route to Southampton the
ship was slowly brought up to speed, to 23.25 knots, the
greatest speed documented for the Titanic.
Officer Changes – Arrival and Departure at
Southampton
Titanic arrived in Southampton on the evening of 3 April, a
little before midnight. The remainder of her crew of 892
boarded the vessel over the next few days.
A coal strike, which had left many ships in
Southampton idle at the dock, threatened the maiden voyage of
Titanic. In addition, a coal fire in Bunker 10, located on the
starboard side of Boiler Room 6, ignited when the ship left
Belfast and was not extinguished until 9 April.
At this point there was a major shake-up in the roster of
Captain Smith’s deck officers, which remains unexplained. The
Chief Officer of Olympic, Henry Tingle Wild, was transferred
to Titanic as new Chief Officer, displacing the original Chief
Officer, William McMaster Murdoch, who was bumped down
to First Officer. The former First Officer, Charles Herbert
Lightoller, was now the Second Officer. The Second Officer
left the ship (in a stroke of fate that saved his life), and the
junior officers, Third Officer Pitman, Fourth Officer Boxhall,
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
17
Fifth Officer Lowe and Sixth Officer Moody, retained their
positions. It is believed that when the former Second Officer
left the ship he inadvertently locked the binoculars in his
cabin’s closet, where they had been kept for safekeeping during
the sea trials, and unfortunately left the ship with the key.
These unexpected changes in deck officers and last
minute shifts in responsibilities, along with a crew of 892
joining a new ship, were sure to create major problems. This
crew had never worked together before. While the Board of
Trade Inspector had as a standard procedure required two boats
to be lowered and launched prior to the sailing, no complete
boat drill was ever held. The passengers had no idea which
lifeboat they were assigned to, where it was located, which
deck they should embark from or which officer was assigned
the boat; the same held true for the crew. There was something
approaching a watch, quarter and station bill for the crew, but
drills were never conducted. This was evidenced by the
confused muddle on the boat deck the night of the sinking,
when crewmen to man the boats could not be found and scratch
crews, inadequate both in number and training, were in charge
of the boats. Specific officers were not even assigned to
oversee specific boats. This is a major oversight in command
and amounts to neglect of the safety of both passengers and
crew.
It was also at this time that the eight musicians hired
from a Southampton agency boarded the ship, headed by
Wallace Hartley, with J. Hume, C. Taylor, J.W. Woodward, R.
Bricoux, F. Clark, G. Krins and W.T. Brailey. The band
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
18
 members would later
become famous for their
legendary performance
aboard Titanic, playing
music on the open boat
deck to the very end.
On Wednesday
10 April, Titanic
departed Southampton
on her maiden voyage
with 1,316 passengers
and a total of 2, 208
persons on board
according to the
Certificate for Clearance
issued by port officials
that day. It was at this
time that the Titanic, while leaving its berth, almost collided
with the New York, as mentioned above.
Cherbourg
After dropping off the pilot at the Nab Lightship, Titanic
proceeded on a southerly course across the channel to
Cherbourg, arriving shortly after 1800. She dropped anchor at
about 1830. Here she would moor, since there were no docks to
accommodate her. At this port, 13 First-Class and seven
Second-Class passengers left the ship. Passengers and baggage
were ferried out to Titanic by two White Star tenders, the
Nomadic and Traffic. First-Class passengers coming aboard
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
19
numbered 142 and included names such as Cardeza, Sir Cosmo
and Lady Duff Gordon (incognito using the name Morgan) and
Benjamin Guggenheim; the famous marine artist Samuel Ward
Stanton was among the Second-Class passengers. After a brief
stay at anchor of about one hour 30 minutes, the Titanic
weighed anchor and departed at about 2000, steaming for
Queenstown (now Cobb), Ireland.
Queenstown and the Final Departure
The ship left the French coast proceeding on a westerly course
during the evening hours of 11 April, turning northwest after
passing Lands End, transiting the St. George Channel and
arriving off Queenstown at about 1130. There were no
incidents of consequence reported during this leg of the
voyage. The ship anchored approximately two miles offshore
and passengers and mail were transported via tender. The
Titanic took on 1,385 bags of the Royal Mail and 120
passengers. Seven passengers left the ship at Queenstown, and
one crewman, stoker John Coffee, deserted the ship.
Titanic weighed anchor off Queenstown at about 1330
after only a two-hour stay, taking a westerly course
approximately 45 nautical miles off the Irish coast and slowly
working up to her cruising speed. J. Bruce Ismay, White Star
chairman, is reported to have had a conversation with Chief
Engineer Joseph Bell concerning Ismay’s wish to operate the
ship at its top service speed on 15 or 16 April, that Monday or
Tuesday, if weather permitted. Ismay later admitted to this as
his intention, although there were no surviving witnesses to
attest to this conversation. Somewhere around tea time Titanic
passed the Fastnet Light and by dinner darkness had set in and
the Irish coast disappeared as she started her transatlantic
course. It was at this time that the ship’s lookouts again
requested binoculars, which could not be located.
The Transatlantic Crossing
The evening of 11 April passed without incident as passengers
and crew alike settled down to their new surroundings and the
ship’s routine. Breakfast was served Friday morning, 12 April
between the hours of 0830 and 1030, lunch at 1300 to 1430 and
dinner at 1800 to 1930 – a leisurely shipboard schedule set
around the bountiful meals prepared by the Titanic’s expert
chefs. As prescribed by the company’s regulations, a daily
ship’s inspection was conducted each morning by the captain,
at 1030, of the public rooms in all three classes, galleys, stores,
etc. At the machinery spaces he was joined by Chief Engineer
Bell, who accompanied the captain throughout the engine,
boiler and auxiliary spaces. This was followed by a conference
with the deck, engineering and steward department chiefs.
It was popular during this period for transatlantic
passengers to form pools to wager on the distance made by the
ship from noon to noon, when the ship’s position and distance
made in the last 24 hours would be posted in the lounges and
smoking rooms. One such passenger, Lawrence Beesley,
relates in his book, The Loss of the S.S. Titanic, that he made a
record of these distances that has proved invaluable in
determining the ship’s actual speed during the course of the
voyage. The log book, Night Order Book and navigational
charts of the Titanic were not placed in any of the lifeboats, as
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
20
would be expected, and went down with the ship. From 1200
Thursday, 11 April, to 1200 Friday, 12 April (including time
spent at anchor off Queenstown, Ireland) the ship made 386
nautical miles at a speed of 16.08 knots. From 1200 Friday, 12
April, to 1200 Saturday, 13 April, the ship travelled 519
nautical miles at a speed of 21.625 knots. This represents a full
24-hour period on the open seas. From 1200 Saturday, 13
April, to noon that fateful Sunday, 14 April, Titanic steamed
546 nautical miles at a speed of 22.75 knots. She was slowly
and carefully running up the engines and increasing speed in
measured increments, lending credibility to Ismay’s declared
intentions of running her at full speed on 15 or 16 April. Good
weather still prevailed and there were at least to this point no
significant incidents of record.
On Sunday, 14 April, the noon position was taken and
noted as a fix on the chart and a dead reckoning plot was made
indicating course above the line and ship’s speed below from
the noon position. Dead reckoning navigation uses the last
known position of the ship as a “fix,” with the ship’s speed and
course projected to approximate a future position without
allowances for wind or current. It was and is still commonly
used, but it was subject to inaccuracy in the case of the Titanic
as shall be noted later in this report.
Sunday, in the late afternoon or early evening, the
ship’s wireless broke down. Communication ceased. Senior
Marconi Operator Phillips and his assistant Harold Bride began
a long and complex search for the problem in an effort to bring
the radio back on-line. According to Bride, “And that reminds
me – if it had not been for a lucky thing, we never could have
sent any call for help. The lucky thing was that the wireless
broke down early enough for us to fix it before the accident.
We noticed something wrong on Sunday, and Phillips and I
worked seven hours to fix it. We found a secretary [read as
secondary transformer] burned out, at last, and repaired it just a
few hours before the iceberg was struck” (New York Times,
April 28, 1912). The delay this caused in sending private
messages from passengers caused a serious backlog for the
already tired Marconi operators.
The weather on the voyage was thus far near perfect;
according to statements made by Second Officer Lightoller the
sea was “smooth as a proverbial millpond, not a breath of wind
and a sea of glass” (Charles Lightoller, BBC interview
recorded 1936). According to Fourth Officer Boxhall on the
12:00 to 4:00 watch that evening, when the Titanic struck the
iceberg, “It was a clear night with no sign of fog, the sea was
perfectly smooth, there was no moon, every star in the heavens
could be perfectly seen” (CDR Joseph Boxhall, BBC interview
recorded 1936).
By mid-morning Sunday the Titanic had received radio
messages from the Caronia and the Noordam of ice ahead. By
early afternoon the Baltic had reported a large ice field thought
to be 250 miles in advance of Titanic’s dead reckoning
position. A third message, from Amerika, also warned of ice
but it was addressed to the U.S. Navy Office in Washington,
DC, and was not delivered to the captain.
The eastbound SS Rappahannock passed so close to
Titanic that at about 2230 (just an hour before the Titanic
struck the iceberg) she signaled by Morse lamp instead of
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
21
radio, warning Titanic that she had just passed through a heavy
ice field and had sighted several icebergs. The message was
acknowledged by Titanic. Notwithstanding this later warning
with very fresh information, no attempt by the watch officers
was made to slow the ship down, alter course or notify the
captain. At about 1800 Captain Smith ordered a change in
course to South 86 degrees West, True (266) and held the ship
at full speed. At about 1930 the Californian sent a message that
they had spotted ice approximately 50 nautical miles ahead of
Titanic. At 2120 Captain Smith came on the bridge, spoke with
Second Officer Lightoller (Senior Officer of the Watch),
discussing the weather, calm seas, and indications of ice, then
retired for the evening to his cabin. The conversation with the
captain ended with Smith saying, “If it becomes at all doubtful
let me know at once; I will be just inside.” Lightoller then
ordered lookouts to be cautious of ice until daylight. Titanic’s
speed was estimated to have been 22 knots (Loss of Steamship
Titanic – Senate Report of Investigation, 62nd Congress, 2nd
Session, Document No.933, Washington, DC, 1912).
At about 2140, two hours before the collision, a
crucially important message was received in the Titanic’s radio
room from SS Masaba, henceforth known as the Masaba
message. The message clearly indicated the nearby presence of
significant ice in the immediate area of Titanic. The message
was not received by the bridge or any of the ship’s officers.
The following is the text of the Masaba message:
From: Mesaba To: Titanic and all eastbound ships:
Ice report in latitude 42N to 41.25N longitude 49 to longitude
50.30W. Saw much heavy pack ice and great number large
icebergs. Also field ice. Weather good, clear.
 Notwithstanding, the U.S. Senate Investigation found
that Captain Smith, First Officer Murdoch, Second Officer
Lightoller and Sixth Officer Moody all knew Sunday evening
that the Titanic was entering a region where ice might be
expected, the ship did not reduce speed until the collision was
unavoidable.
Second Officer Lightoller, who had been on watch at
the time the Masaba message was received by Titanic, said in
his recorded statements that, “A very vital message had never
been reported to the bridge. The message came from the
Mesaba in an area right ahead of the Titanic and not far away,
warning of the most vital importance. If it came to my hand, I
would have slowed her down at once and sent for the captain.
We were steaming at 22 knots. At ten I was relieved by W.M.
Murdoch” (BBC Recording 1936).
Thirty minutes later the Californian began to send a
message to Titanic saying she had stopped for the night and
was surrounded by ice, but the message was cut off as the
Titanic radio operators were attempting to pass private message
traffic to the Marconi station at Cape Race, Newfoundland.
Irritated by a terse remark to shut-up, the sole wireless operator
aboard the nearby Californian turned his set off and retired for
the night.
At about 2340, the watch officers on the Titanic’s
bridge were alerted to trouble by the two lookouts, Fleet and
Lee, in the crow’s nest, sounding the warning bell three times,
quickly followed by a telephone call to the bridge warning,
“Iceberg right ahead.” Second Officer Murdoch, upon hearing
the telephone message, relayed by Mr. Moody, immediately
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
22
rang the engine order telegraphs to STOP and then to FULL
ASTERN. Simultaneously he ordered Quartermaster Robert
Hitchens to put the wheel hard-a-starboard in an attempt to
swing the ship’s head around the iceberg passing on the
starboard side. (It should be noted that before a 1928
international convention changed ships’ steering systems’
rudder controls, the linkages and orders given were based upon
an earlier day when sailing ships were controlled by tillers.
Thus to put the tiller over to starboard would place the rudder
to port and the ship would turn to port. Authors not familiar
with common maritime steering commands of the day
theorized that the wrong order was given, but this was not
true.) Murdoch then pushed the switch that sounded the
warning bell and closed the watertight doors below deck. There
was no question as to the seriousness of the collision in the
engineering spaces – only two stokers and an engineer escaped
Boiler Room 6 before it flooded and the watertight doors
closed.
The estimated time of impact of with the hull with the
iceberg was 30 seconds from the first sighting, not allowing
sufficient time to turn the vessel any appreciable degree or to
quickly respond to the engine orders.
The iceberg scraped an estimated 300 feet along the
starboard side well below the waterline, from the forepeak
hatch to Boiler Room 6. (Boiler rooms on the Titanic were
numbered in such a manner that Number 6 was the most
forward and Number 1 was aft just before the engine rooms.)
This glancing blow immediately caused flooding in the first six
watertight compartments as far back as Boiler Room 6.
 In 1936, 24 years after the sinking of the Titanic,
Joseph Boxhall recorded his eyewitness account of the night
the ship sank for a popular BBC radio series. According to this
recording, Boxhall had gone on watch at 2000 with Murdock
and Moody. He had been handed a set of stars by Lightoller
that Lightoller had taken by observation during the second dog
watch, but Lightoller had not yet computed the sight reductions
to indicate that ship’s actual position. In the merchant marine
the long-established practice is that the relieved watch who
took the stars would work out the position and record it on the
chart for the relieving watch, so that when the new watch took
over he would have the ship’s position updated to the end of
the relieved watch. Boxhall, beginning his watch, worked out
the position based on Lightoller’s stars and found Titanic to be
just over 20 nautical miles ahead of her then-plotted 2000 dead
reckoning position. He left the bridge to get a cup of tea and
felt the scraping and vibration while walking about 60 feet to
the bridge and stated that it did not even break his step. Boxhall
arrived on the bridge just as Captain Smith arrived. Boxhall,
hearing that the ship had struck an iceberg, immediately went
forward without being ordered to look for any apparent
damage. A quick inspection revealed nothing, not even a
cracked porthole.
Returning to the bridge he informed the captain of what
he had found. Captain Smith instructed him to go below and
find the ship’s carpenter and have him sound the ship round
forward. He hadn’t descended far down the four sets of ladders
when he met the carpenter, out of breath, coming up. The
carpenter informed him that the forepeak hatch was blown
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
23
away and that the tarpaulins on Number One Hold were
ballooning up (a certain sign that the hold was taking on water
rapidly, which was compressing the air in the hold and
ballooning the tarps over the hatch covers). He told Boxhall
that she was evidently taking on water fast. Boxhall instructed
him to report immediately to the captain.
Descending further down the ladder towards the mail
room, he met the mail clerk coming up, who reported that the
mail and sorting rooms were flooding. He went to the mail
rooms through the Main Salon entrance because all the
watertight doors were closed; in the salon he noticed the band
tuning up. Reaching the sorting room he found all the clerks
pulling letters from the racks; descending the ladder to the mail
room, he saw green sea water swirling along the bottom rungs
as a mail bag floated past him, carried by the current of
invading water. He knew at that point it was very serious and
quickly retraced his steps to the bridge, passing the Main Salon
entrance just as the band struck up “Alexander’s Ragtime
Band.”
He reported his observations to the captain and asked if
the dead reckoning position shouldn’t be computed and
advanced based on Lightoller’s set of stars and then advanced
to their current position, where they had struck the iceberg.
This was crucial information, since Captain Smith had already
given the old dead reckoning position to the radio room to send
out in the distress calls – rescue ships would be looking for
Titanic’s boats in the wrong position.
The importance of this was never fully brought to light
by the inquiries – the largest passenger ship in the world,
through inadequate navigation practices, did not know where it
was and how close it was to reported ice warnings, while
charging ahead at full speed. They knew where they were after
striking the berg but not before! Titanic was in actuality over
20 nautical miles ahead of the old dead reckoning position and
much closer to the ice fields than any of the ship’s officers
realized. Boxhall worked out the amended position based on
Lightoller’s stars, which he then carried to the radio room and
handed to Phillips, who had already sent out the distress
messages using the faulty position handed him by Captain
Smith. He explained to Phillips the importance of sending out
the amended position at once.
Shortly after the collision a quick conference was held
on the bridge with Captain Smith, Ismay, Chief Engineer Bell
and Thomas Andrews of Harland & Wolff. Smith, Andrews
and Bell conducted a hurried tour of the damaged areas and
returned to the bridge. Ismay made a private tour below decks
with the chief engineer, who was of the opinion that the
damage was significant but that the pumps could keep up with
the flooding. Andrews, who knew the ship better than anyone
else aboard, made a quick assessment that the ship was fatally
damaged since all of the forward watertight compartments
were flooded as far aft as Boiler Room 6. It was Andrew’s best
estimate that Titanic would sink within two hours.
Through the dedicated and heroic efforts of Chief
Engineer Bell and his 25 engineering officers, the ship stayed
afloat for 2 hours, 40 minutes, buying valuable time to load the
lifeboats and abandon ship. Their dedication also kept the
lights on Titanic ablaze almost until she slid beneath the waves.
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
24
This gave those still trapped below and trying to find their way
topside a chance to escape and provided much-needed light on
the upper decks to facilitate the lowering of the boats.
Smith gave the order for the lifeboats to be uncovered
and the crew mustered. While not documented, it is believed
that there had to be some discussion among Smith and his
officers on the bridge concerning the inadequate capacity of the
lifeboats and Smith’s fear of a panic and stampede. It would
have been at this time and for this reason that Smith distributed
the loaded Webley revolvers to each of the officers and would
have issued his orders for their use, if necessary, and for
women and children to be loaded first into the boats. This last
order was interpreted by some of the officers as “women and
children only” and accounts for many of the earlier boats being
sent off with so few occupants and couples being separated.
Almost immediately after striking the iceberg and
stopping dead in the water, all of the pressure relief valves on
the Titanic’s 29 Scotch Marine, fire-tube boilers lifted due to
the sudden build-up in steam pressure, which exceeded their
215-psi standard operating pressures. This was caused by the
curtailment of steam demand from the three main propulsion
engines, which until moments before were at or near full
power. Shortly after this it became necessary for the engineers
to quickly blow down the boilers and kill the fires to relieve the
pressure. This minimized the possibility of boiler explosions
due to the furnaces and crown sheets melting or collapsing and
water and steam under pressure collapsing into the furnaces.
The sound this created as the steam roared through the eight
vents, located atop the four stacks, was deafening on the boat
deck and the bridge. The roar was so loud the officers had to
cup their hands and shout in the ears of crewmen attempting to
strip the boat covers and lower boats in their davits. The
roaring steam discharge also made it difficult for the Marconi
operators to hear radio signals in their earphones. Many of the
survivors recall the deafening roar while the boats were being
loaded. Steam pressure, however, had to be maintained on
some of the boilers nearest to the engine room and furthest aft
in the ship. This was necessary to operate the ship’s auxiliary
systems, keep the pumps running and provide steam for the
reciprocating engines powering the ship’s electrical generators
and communications.
Radio Telegraphy and Distress Messages
The first of Titanic’s distress calls was received by the Cape
Race, Newfoundland, Marconi Station MCE at 0015, 15 April,
and by the steamships Mount Temple MLQ, Frankfurt DFT,
and Provence. This call had the Titanic’s original, incorrect
dead reckoning position and was sent 35 minutes after the
collision. At 0025, a full 45 minutes after the collision,
subsequent distress calls were sent using Boxhall’s amended
position. After several subsequent distress CQD calls, the first
SOS call was sent at 0045. By 0127 Titanic sent “We are
putting women off in boats.” At 0145 Carpathia MPA picked
up the last signal it received from Titanic. At 0147 Captain
Smith released the radio operators from their duties, saying,
“You can do no more, abandon your cabin. Now it’s every man
for himself.” At 0217 Titanic’s signals ended abruptly as the
power failed. Titanic’s radio operators had sent out a
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
25
continuous stream of distress message traffic for two hours and
two minutes. When the power failed and water was rushing
into the adjacent bridge and wheelhouse, Phillips and Bride
abandoned the radio room.
The Evacuation of Passengers, Filling and
Launching Boats
At about 0025 Captain Smith ordered the crew to inform
passengers that they should assemble on the boat deck. Since
there was no general alarm bell and no public address system
to alert passengers and crew, this task had to be performed by
stewards knocking on doors and making announcements in
passageways. Chief Officer Wilde ordered Second Officer
Lightoller to oversee the preparation of the boats. Lightoller
worked his way down the port side to the last boat aft and then
up the starboard side to Boat 3. The two emergency cutters,
Boats 1 and 2, were always kept swung out in their davits
ready for quick launching should someone fall overboard.
Boats with odd numbers were located on the starboard side of
the deck, while even numbered boats were on the port side.
First Officer Murdoch supervised the loading and
launching of lifeboats on the starboard side while Second
Officer Lightoller did the same on the port side. The plan was
to work from the forward-most lifeboats (3 and 5 starboard, 2
and 4 port), working their way aft along the boat deck.
Problems and delays quickly arose in the loading, launching
and manning of the boats due to three factors. First, the crew
had little or no training in the launching of the boats and did
not know their lifeboat stations. Second, the officers were not
aware of the rated capacity of the lifeboats and the fact that the
boats were designed to be launched from their davits and
lowered to the water while filled to their rated capacity. Third,
the crew had never participated in lifeboat drills where they
had to report to a specific boat, launch the boat and then crew
it. A designated officer or petty officer should have been
assigned to take charge of each of the boats when it was
launched; this was not the case.
This haphazard approach was to prove fatal for
hundreds of people. Testimony from the officers and survivors
at the Board of Inquiry in London claimed that a total of 854
persons were placed in the lifeboats; adding those rescued from
the water the total saved was 914. However, Carpathia took
only 712 persons onboard. The inquiry states, “Allowing for
those subsequently picked up, of the 712 persons save only 652
could have left in the Titanic’s boats, an average of about 36
per boat” (Loss of Steamship Titanic Report, pg. 51).
This series of failures in command and due care led to
the needless loss of hundreds of lives when the lifeboats,
inadequate in number as they were, had not been loaded to
anywhere near their rated capacities. The loss of life was
further increased by the fact that, once launched, only a few
boats returned to pick up survivors struggling for their lives in
frigid water. Even though more than ample space was available
in almost all of the boats, and they were certainly within sight
and sound of people pleading for help, most of the boats
refused to help. The screams were said to have lasted for over
an hour.
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
26
Loading the Lifeboats
Boat 7 was the first to be lowered at 0045 (one hour and five
minutes after the collision) with only an estimated 30 persons
on board. This boat had a rated capacity of 65 persons and
could probably handle slightly more in a calm sea with no
wind, such as existed that evening.
At about this time Fourth Officer Boxhall began to fire
a series of distress rockets from the bridge wing in the hope of
attracting the attention of a ship within sight slightly over the
horizon. There had been repeated earlier attempts to signal her
with a powerful Morse Lamp to no avail. Boxhall, according to
his and other statements could clearly see this ship with the
naked eye. It was so close he could make out all of her lights
and see light from her portholes. He continued to fire the
distress rockets, which soared to a height of 800 feet before
exploding with a sharp report and showering a dozen bright
white stars. Eight rockets were set off at five-minute intervals.
Also at about 0045 disaster took place in the engine
spaces. The watertight bulkhead between Boiler Rooms 5 and 6
gave way, killing all in Boiler Room 5 except for one crewman
who managed to escape drowning. The collapse of a watertight
bulkhead on a new ship implies a problem with construction or
design or undetected collision damage. The bunker fire in
Boiler Room 6 bears investigation as a probable cause for
weakening this bulkhead. This bulkhead failure brought sea
water up against the watertight bulkhead in adjacent Boiler
Room 4.
Boat 5 was loaded and lowered by Third Officer Pitman
with an estimated 36 to 40 persons aboard; this and all the
other standard lifeboats were rated to carry 65 persons. This
boat and its officer would later come under scrutiny for the
officer’s alleged refusal to pick up survivors struggling in the
frigid water.
Boat 6 was loaded and lowered by Second Officer
Lightoller at 0055 with approximately 27 persons. At this time
the ship was taking on a definite starboard list.
Boat 3 was next with only 40 persons on board.
First Officer Murdoch and Fifth Officer Lowe loaded
and lowered Emergency Cutter 1 at 0110 with only 12 people
onboard. The passengers consisted of Sir Cosmo and Lady
Duff Gordon, her private secretary, Miss Francatelli, and a full
complement of crewmen. This boat was rated to carry 40
persons. This boat was also the subject of deep inquiry and
allegations of possible immoral if not criminal behavior on the
part of the Duff Gordon’s, who allegedly refused to help those
in the water; they allegedly bribed the crew with checks for
five pounds each to not return to pick up survivors, including
many women and children whose cries where clearly heard
from only about 600 feet away. Copies of a cancelled check
drawn to one of the crewmen remain as evidence of some sort
of payment to the lifeboat’s crew.
Chief Officer Wilde and Second Officer Lightoller
loaded and lowered Boat 8 with 28 passengers and 4 crewmen,
half the rated capacity.
Boat 9 was loaded and lowered by First Officer
Murdoch and Sixth Officer Moody at about 0120. There were
only 46 people in the boat including eight crewmen.
Boat 10 was lowered on the port side with 41 people on board.
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
27
On the starboard side there was more of a sense of
urgency and danger as Boat 11 was lowered at 0125 with 70
persons. Again, this is a standard boat rated for 65 persons but
obviously could handle more. All of the other standard
lifeboats could have safely carried 70 as well if properly
loaded.
Boat 12 on the port side was lowered at about the same
time with an estimated 26 to 28 passengers and two crewmen.
More lives were squandered by sending many of boats off,
even at this late stage, less than half full.
Boat 14 was lowered. Chief Officer Wilde ordered Fifth
Officer Lowe to take charge of this boat. It carried 42 to 45
people including crew.
Boat 13 was lowered with about 65 persons. It was
nearly crushed by Boat 15 when one of Boat 13’s forward falls
failed to release and it drifted under Boat 15 while Boat 15 was
being lowered. Quick action by the crew averted disaster.
Within minutes Boat 15 hit the water with
approximately 65 persons onboard. This boat was remarkable
in that it was one of the few to carry any Third-Class
passengers. It should be noted that 13 boats had been lowered
and were away before the first of the Third-Class passengers
(women and children) were accommodated.11 There is strong
evidence that passengers from Third- and even Second-Class
were hindered in their attempts to reach the boat deck by
locked gates and crewmen, notwithstanding assertions to the
contrary from witnesses and members of the London Board of
Inquiry. That this was not only negligent but possibly criminal
 conduct was never pursued by either of the two boards
conducting investigations.
By this time the Titanic had settled significantly down
by the bow with an increasingly noticeable starboard list, so
much that it impaired the loading and lowering of starboard
boats.
Boat 16 was loaded and lowered with some difficulty,
carrying only 40 passengers and crew. It was one of the two
remaining standard lifeboats.
First Officer Murdoch at this point went forward to
lower Englehardt Collapsible Boat C. This was no easy task
because the boat had to be manhandled from the roof of the
officers’ quarters down to the boat deck. He was forced to fire
his pistol when an attempt was made by several men to rush the
boat.
Boat C was finally launched with approximately 40
passengers and crew. Ismay is alleged to have pushed his way
through a crowd of men to get aboard this lifeboat. His
presence on this boat was a cause of considerable criticism in
the press, where he was condemned for seeking a seat in one of
the lifeboats when so many of his passengers, many of them
women and small children, perished. The allegation was made
but not proven.
Boat 2, the port side emergency cutter, was lowered
away at 0145 (35 minutes before the ship foundered) with 18
persons onboard; it is rated to carry 40. Fourth Officer Boxhall
was ordered into the boat by Captain Smith and told to go
around to the side port on the starboard side to load additional
passengers who would be waiting there. Boxhall, in a recorded

The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)

28
BBC broadcast, told of his precarious trip in this boat from the
port side bridge wing, around the stern of the Titanic and under
the stern and the massive propellers, which by this time were
out of the water. He was amazed to see no other lifeboats on
the port side. When finally rowing around to the side entrance
port, which had been opened to disembark passengers into the
lifeboats, Boxhall was worried about the enormous crowd that
had gathered there. He was fearful that if he came alongside, a
mass of people would jump from the open port into the small
cutter. He pulled away from the ship and stood off at a
considerable distance.
Boat 4 was finally lowered at about 0155 (25 minutes
before the ship sank) after considerable trouble with the falls.
Even at this late time it was lowered away with only 36 persons
including four of the crew and one Chinese stowaway.
At about 0205 (15 minutes before Titanic sank) on the
starboard side forward, Collapsible D was successfully
lowered. It carried only 22 persons. Less than half full it rowed
away from the side of the ship.
At this point less than 15 minutes remained and
hundreds of people were gathering on the steeply inclined
decks. Many passengers, finally freed from below and from
Third Class, found all of the boat davits empty and not a
lifeboat in sight. The Titanic’s orchestra was on deck playing
ragtime melodies for the crowd of passengers. An Irish priest
was hearing confessions near the fantail. Anguish permeated So many people would die needlessly that night,
the atmosphere along with a sense of hopelessness and the including 52 children from Third Class. None of the children
certainty of imminent and horrific death. from First Class and Second Class perished.

The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)

29
 The two boats remaining on Titanic at this time
(Collapsibles A and B) floated off the roof of the officers’
quarters when the rush of sea water reached the boat deck
forward by the bridge and wheel house. Twenty people swam
to Collapsible A, which floated upright but without the sides
installed. Because of this, cold seawater flooded the boat, so
that when eventually rescued by Carpathia, it carried 12
survivors and 8 corpses.
Collapsible B capsized when it was washed off the ship.
Nonetheless, nearly 30 men were able to carefully stand in
knee-deep water balancing on the upturned boat throughout
that long and cold night. Second Officer Lightoller survived,
while another important player in the events of that horrific
night, Senior Marconi Operator Phillips, perished from
exposure. While on the raft-like structure of the upturned boat,
Phillips relayed to Lightoller the contact he had made with
various vessels and the fact that Carpathia was en route to
rescue survivors. It was at this time that he told of receiving the
Masaba message, and how in the rush of his duties he had set it
aside under a paperweight for later delivery to the bridge. This
was the message, warning of a large ice field in the Titanic’s
path, that could have turned the course of history.
Death, the Aftermath and Eventual Rescue
Eyewitness accounts speak of the fact that Titanic’s lights
blazed on to the very end, testament to the heroism of the
engineering officers, not one of whom survived. Many of the
engineering crew died with them. They kept the steam pressure
high enough to run the pumps and delay the sinking. They kept
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
30
the generators for the radios, stairway and accommodation
lights and all the interior lights and deck lights ablaze to the
very end. If they had evacuated the engineering spaces much
earlier, hundreds would have been trapped below in a maze of
blackened passageways and ladders. Launching the boats in the
pitch black would have made matters even worse than they
were.
At about 0218 the lights on Titanic dimmed, went out
briefly, came back on brightly, flashed and went out forever.
At 0220 the ship foundered, and those attempting to launch the
collapsibles atop the officers’ quarters’ roof were swept away
by the onrush of water. The foredecks were below the surface
and water advanced up the boat deck. The forward stack guys
parted and the stack crashed down into the sea, just missing the
overturned collapsible. Hundreds either jumped or were swept
into the sea as the great ship plunged to the bottom, some
12,600 feet below the surface.
The screams and pleas of hundreds were heard by the
survivors in the boats, some as close as 600 feet. Although
there was ample room for many more in the lifeboats, almost
none returned to help, afraid of being swamped. Ironically, for
many it was their husbands or fathers or other loved ones in the
water to whom they turned a deaf ear. By 0235 to 0250 most of
the screams of survivors in the water had abated and many
were dead from hypothermia from being immersed in 28-
degree Fahrenheit water for over 30 minutes. Fifty-two young
children died sooner than their adult parents from the freezing
cold.
 Fifth Officer Lowe’s boat (Boat 14) was one of the few
that returned to seek survivors, after joining a number of boats
together and redistributing the passengers to make more room
in the rescue boat. Six people were rescued; another 14 were
taken off the partially submerged hull of Collapsible A, which
was then cast adrift. Still onboard were three unknown corpses.
Lifeboats 4 and 12 rescued another 28 survivors perched atop
the overturned Collapsible B.
It was a cold and very dark evening with flat calm seas,
a slight breeze and no moon, just thousands of stars in the sky
above. For those still in the water, afloat in their rigid, white,
cork lifejackets, death would come slowly and painfully in the
cold waters of the North Atlantic. Many in the lifeboats were in
shock and chilled to the bone. It was found that most of the
lifeboats lacked even the most basic required equipment –
water, provisions, compasses, lanterns, green lights (flares),
even oars were missing. This was ironic on a new ship that had
just been inspected by the Board of Trade’s representative and
declared seaworthy in all respects. The inspector had allegedly
allowed White Star to store the lifeboat equipment in a nearby
place for use when needed, but not in the boats where it should
have been. Fourth Officer Boxhall had the presence of mind to
bring along a tin of green lights to assist the rescue ships in
locating the Titanic survivors.
At about 0330 the first of the Carpathia’s rockets were
sighted. Boxhall, in Boat 2, ignited a series of green lights to
assist her in locating the survivors. At 0410 Boat 2 was the first
of Titanic’s lifeboats to arrive alongside the Carpathia. After
safely discharging his passengers into the hands of rescuers, he
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
31
reported to Captain Rostron, who inquired where the Titanic
was; Boxhall reported that she had sunk. By 0830 all of the
lifeboats had been recovered and Carpathia cruised over the
water looking for additional survivors but located no living
persons. As she was preparing to depart for New York she
encountered the Californian just arrived\\ing on the scene.
Seventy three years later, on 1 September 1985, Dr.
Robert Ballard, aboard the research vessel Knorr, discovered a
large debris field, the forward hull section and aft section of
Titanic. Based on the location of the boilers, which had broken
free and are believed to have sunk straight to the bottom, it is
estimated that the wreck position was 5.5 nautical miles from
the location at which the Titanic lifeboats were found by
Carpathia. That would suggest that the boats were subject to
significant wind and drift in the six hours they were afloat.
It was also discovered that Fourth Officer Boxhall’s
amended position (based on Lightoller’s stars), which was
transmitted in all subsequent distress calls, was a full 20
nautical miles in advance of the original dead reckoning
position given the Marconi operators by Captain Smith. The
ship wreckage, however, lies at the bottom 13.5 nautical miles
east-southeast of Boxhall’s amended position, slightly south of
the Titanic’s course but much further to the east. This
suggested to Dr. Ballard that Boxhall and the other ship’s
officers may have actually over-estimated the speed of advance
by 2 knots, suggesting that Titanic’s speed was actually 20.5
knots instead of 22.5 knots. The fact remains that in either case
the officers of the Titanic did not know her position until after
the collision, if then. The original dead reckoning position, the
amended position based on Lightoller’s stars and Boxhall’s site
reductions and calculations, the location of the lifeboats when
discovered by Carpathia and the location of the ship’s
wreckage tell a convoluted story.
Findings of Fact
1. Titanic, although registered in the United Kingdom, is in
fact a vessel owned and under the ownership control of a
corporate entity established, registered and incorporated
under the laws of the State of New Jersey and as such
would qualify as a vessel of the United States for regulatory
purposes. Said vessel carried a large number of citizens of
the United States as well as a large number of persons
immigrating to the United States, sufficient for the United
States to establish sovereign jurisdiction in this inquiry and
in the enforcement of its laws.
2. Titanic was a passenger vessel registered in the United
Kingdom and certificated by the British Board of Trade for
the carriage of passengers and dry cargo. Notwithstanding
this, actual ownership and control of the vessel can be
traced directly to both citizens of the United States and
legal entities incorporated under the laws of individual
states of the United States. It is the opinion of the
Investigating Officer that the vessel’s chain of ownership
qualifies jurisdiction of the Titanic as a vessel of the United
States under the federal statutory definition of Vessels of
the United States. In addition, as the direct result of the
number of citizens of the United States who were casualties
in the sinking of Titanic, sovereign jurisdiction should also
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
32
be applicable in subsequent investigations and adjudicatory
proceedings given the foreign vessel’s carriage of United
States citizens and the use of ports within the admiralty
jurisdiction of the United States for the embarkation and
discharge of passengers.
3. Titanic was both designed and built by the firm of Harland
and Wolff in Belfast, Ireland. Construction commenced on
31 March 1909, and the ship was launched on 31 May
1911. The vessel was delivered to its owners on 3 February
1912.
4. The builders designed, constructed and delivered a ship
with at least two major design flaws. One involved the
design of watertight compartments that did not include
watertight hatches or bulkheads or extend all the way to the
strength deck. The second involved the lifeboat capacity of
Titanic; the designers and builders did in fact produce
drawings for and recommend a vastly larger number of life
boats (two sets of plans, for 32 and 64 boats to be
positioned and nested under davits along the entire length
of the boat deck). This design by Harland and Wolff would
have allowed sufficient lifeboat capacity for all those on
board. These plans were rejected by the owner’s
representative, Mr. J. Bruce Ismay, in favor of a 20-boat
plan that would not disrupt the views of passengers on the
top deck. It must be said that the 20 boats on board Titanic
still met and marginally exceeded the minimum
requirements of British regulations established in 1894.
Said inadequate regulations are based on tonnage of vessels
rather than the more logical number of persons to be carried
 on board. In this instance Harland and Wolff should be
dismissed from responsibility for this fatal shortfall of
lifeboat capacity, the decision having been made by the
owners without objection from the Board of Trade.
5. The Titanic’s design had no provisions for a general alarm
bell or other signal to warn passengers to their lifeboat
stations, nor were passengers assigned to specific lifeboats,
nor were any passenger or crew lifeboat drills ever
conducted at any time subsequent to the embarkation of
passengers at Southampton nor at any time during the
voyage.
6. Titanic was certificated to carry 3,326 persons and had total
lifeboat capacity for 1,178 persons. Titanic carried lifeboats
sufficient for 35 percent of the certificated maximum
number of persons allowed.
7. Titanic was under the command of Edward John Smith,
Master. Captain Smith held Extra Masters Certificate
Number 160802 issued by the British Board of Trade.
Captain Smith was directly involved in at least ten prior
significant maritime incidents while sailing under authority
of his certificate and while in command of several different
White Star Line ships. Captain Smith was in command
during four groundings of various ships including RMS
Olympic, one serious collision while commanding Titanic’s
sister ship Olympic with HMS Hawke in which the
Admiralty Court found White Star to be at fault, another
two near-miss collisions, one involving the damaging and
near crushing of a tug while docking Olympic in the Port of
New York and the other while commanding the Titanic
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
33
when it nearly collided with the docked liner New York,
caused by Titanic’s excessive speed in a shallow channel
while departing the Port of Southampton on 10 April 1912.
In addition Captain Smith was in command of the Republic
when it ran aground in New York in 1889. That same day it
also suffered a boiler explosion, killing three crewmen.
Under his command two ships experienced serious fires,
the Majestic in 1901 and the Baltic in 1906. Captain Smith
was in command of the SS Germanic when she capsized in
New York Harbor, the failure to remove ice affecting the
ship’s stability. Captain Smith’s history of four groundings,
a capsizing, another near-miss collision and one very
serious collision never resulted in suspension or revocation
charges being brought against him by British shipping
officials or any other known adjudicatory proceedings. No
known investigations were conducted as the result of the
near-miss collisions. No action is known to have been taken
by British authorities with respect to suspension and
revocation proceedings.
8. Titanic was engaged in an international voyage
commencing from ports in England, France and Ireland
while engaged in intended passage to the Port of New York
in the United States. The subject vessel carrying numerous
citizens of the United States sailed from Southampton on
10 April 1912 to Cherbourg thence to Queenstown before
departing for New York. The subject vessel was engaged in
international commerce and carried both passengers and
dry cargo en route to the United States for hire under
 authority of the certificates of seaworthiness and
registration issued by the British Board of Trade.
9. After a brief stop in Cherbourg to discharge and embark
passengers, Titanic departed Queenstown with a crew of
892 persons of which 73 were assigned to the Deck
Department, 325 to the Engine Department and 494 to the
Stewards Department. This is documented by the
Certificate for Clearance issued by the Board of Trade in
Queenstown, Ireland, on 11 April 1912. The crew included
eight deck officers, including the Master, and another 26
engineering officers. All of the ship’s officers were
certificated by the British Board of Trade and were British
subjects. The Certificate of Clearance listed a total of 2,208
persons on board including crew, which equates to 1,316
passengers on board (606 in first- and second-class cabins
and 710 in steerage). However, this number may have been
offset by at least another 19 persons (who were neither
crew nor passengers) representing eight hired musicians,
three Harland and Wolff employees, two Marconi
Company employees, five postal employees (two U.S. Mail
and three Royal Mail) and one stow-away.
10. At no time after the embarkation of passengers in
Southampton or throughout the entirety of the voyage to its
interrupted conclusion were any lifeboat drills conducted
with the passengers or crew. At no time prior to the sinking
were passengers pre-assigned a lifeboat or informed as to
which boat they should report to in the event of emergency.
At no time was the crew ever mustered at their lifeboat
stations, except for two boat crews during the Board of
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
34
Trade’s inspection. While it is known that Engineering
crewmen were assigned boats and that notices were posted
in their quarters, no drills were ever conducted.
11. The subject vessel received numerous ice warnings from
other ships operating in the immediate vicinity and close to
or near the intended track of Titanic. Notwithstanding these
numerous radio telegraphy messages and at least one Morse
lamp message from a passing ship in close proximity,
Captain Smith willfully and wrongfully failed to slow the
subject vessel to a safe speed. Titanic was rapidly
approaching and progressing through an area of known
navigational hazard at or near her top speed, at night, with
no moon or search lights on flat calm seas. The Master
either knew of or should have known of the extreme danger
in which he placed his ship and its passengers and crew.
12. The ship’s actual position was not known or computed until
after Titanic collided with the iceberg. The significance of
this is profound. Titanic, the largest ship in the world, did
not know its position. The Titanic’s actual position, based
on earlier celestial navigation observations made by Second
Mate Charles Lightoller but not computed until the
following watch, was found to be over 20 nautical miles
ahead of its then current dead reckoning position. Based on
the amended position, plotted by Fourth Officer Joseph
Boxhall, the ship was much closer to and deeper into the
ice fields than believed. The discovery of the wreck of the
Titanic by Dr. Robert Ballard in 1985 revealed that even
this amended position was off. The Titanic’s cylindrical
boilers dropped straight down after the ship foundered,
 providing a good indication of the position at the time of its
sinking. The boilers were located 13.5 nautical miles east-
southeast of Boxhall’s amended position, which in turn was
20 nautical miles ahead of the original dead reckoning
position being used for navigation at the time of the
collision. The boilers were located slightly south of
Titanic’s course but substantially further east. Based on this
new evidence Dr. Ballard believes the ship’s officers
actually over-estimated the speed of Titanic.
13. The initial erroneous dead reckoning position was given to
the ship’s radio operators by Captain Smith. It was
transmitted in the original distress messages. Fourth Officer
Boxhall brought this error to the attention of the captain
and computed a new amended position based on advancing
Lightoller’s stars (and advancing by dead reckoning to the
point of collision). Boxhall personally carried this amended
position to Jack Phillips, Senior Marconi Operator, which
he then transmitted to allow potential rescue ships to locate
the survivors. The ship, aided by either current or wind,
was thought to be traveling at a higher rate of speed and
had thus advanced further along its track and course than
known by the officers on watch. The officers knew they
were approaching a potentially hazardous area but failed to
maintain an accurate plot of the ship’s position.
14. Ship’s deck officers were ignorant of the capacity of the
lifeboats and the fact that they could be lowered to the
water while loaded to their rated capacities. This lack of
knowledge as to capacity and live load capability led to a
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
35
great under-utilization of the lifeboats and many lives lost
unnecessarily.
15. The passengers were not properly evacuated and assembled
with due diligence and dispatch, nor were they assigned
specific lifeboats. As a result many, particularly third-class
passengers, did not appear on deck until the late stages of
evacuation when most of the boats had been lowered. In
many cases third-class passengers were impeded,
obstructed and blocked in their attempts to reach the boat
deck and the lifeboats.
16. The officers in charge of loading and lowering the lifeboats
knew or should have known of the rated capacity and
properly loaded the boats to achieve at least 100 percent of
the rated capacity. As a result of their professional
negligence, nearly all of the Titanic’s lifeboats were
lowered with only a fraction of their rated capacity, causing
over 400 deaths.
17. The ship’s Master, Captain Smith, failed to exercise due
care and diligence in command, navigation and
management of the vessel, its crew and passengers before,
during and after the collision. No lifeboat drills were
conducted with the crew (new to the ship, its equipment
and to each other); no lifeboat drills were conducted with
the passengers; the ship operated at the highest possible
speed through an area of known navigational hazard despite
numerous and repeated warnings from other ships in the
vicinity; the position of the ship was uncertain and
incorrect at the time of collision; a timely warning and
notice to all of the passengers to evacuate and notice of the
 true extent of the imminent danger was not communicated;
the ship’s lifeboats we improperly loaded, often at a
fraction of their rated capacities; certain third-class
passengers were impeded and hindered in their progress to
escape to the boat deck; initial distress calls were sent out
with the ship’s wrong position; lifeboats for the most part
were not properly manned or instructions to return to pick
up as many survivors as possible were not given; and the
lifeboats themselves were not properly equipped as
required by regulation particularly with respect to lanterns,
knives, hatchets, water, provisions and green lights.
18. Certain officers and crew in charge of the individual
lifeboats after their launching negligently, willfully and
wrongfully failed to attempt to rescue, and in at least two
known instances outright refused to rescue persons in the
water who were in grave danger and were pleading for
assistance within their hearing and/or within their sight.
Although these lifeboats were seaworthy and fully capable
of effecting a rescue and in all but a few had ample surplus
capacity (often more than 50 percent) to save lives, officers
and crew in charge did absolutely nothing. The
Investigating Officer recommends that such evidence as
exists be turned over to the United States Attorney for
further investigation and criminal prosecution for
involuntary manslaughter12 in the two instances of affirmed
refusal cited and for involuntary manslaughter in other such
instances where evidence may be sufficient for prosecution.
19. In one reported instance the boat crew was influenced by
passengers in Boat Number One to not return to rescue
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
36
persons within sight and sound, drowning and in distress in
the water. It is estimated the distance was approximately
600 feet. It is further alleged that one passenger influenced
actions or inactions of the crew by offering and tendering a
bribe to each crewman – to wit, a check, drawn in the
amount of five British pounds sterling. Said lifeboat had a
rated capacity of 40 persons and carried 12 persons
including crew at the time of the alleged criminal acts. The
Investigating Officer recommends the Board turn over such
evidence as exists to the United States Attorney for further
investigation and prosecution.
20. The inadequacy of the British Board of Trade’s maritime
safety regulations as to ship construction and equipment
and the inadequacy of the Board of Trade’s inspectors to
ensure that lifeboats carried the required and necessary
equipment on board (in all instances none had compasses
and only three had lamps) should be brought to the
attention of the British government through appropriate
diplomatic channels.
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
37
Charges and Specifications
1. Gross negligence of the Master of RMS Titanic in the
unsafe navigation and command of the vessel at an
excessive, unsafe and dangerous rate of speed in an area of
known navigational hazard and one which was the subject
of repeated and timely ice warnings from other vessels in
proximity.
2. Negligence in the failure of the Master to order, effect and
supervise lifeboat drills for the crew and the passengers,
and to properly train the crew in the capacity, loading,
lowering and handling of the lifeboats.
3. Failure of command by the Master to notify and alarm with
dispatch all passengers of the imminent danger to the ship
and to ensure their unimpeded passage to the boat deck
regardless of class of passage and to efficiently organize
the timely evacuation of all those aboard who could be
accommodated in the lifeboats, as inadequate in number as
they were.
4. The failure and negligence of certain watch officers
preceding the collision to compute the sight reductions of
stars taken earlier in the evening and to properly advance
the dead reckoning position based upon this most recent
fix, duly notifying the Master of the ship’s then known
position to be at least 20 nautical miles in advance of the
earlier dead reckoning position and thus closer to and
deeper into the area of danger.
5. The failure of certain officers to properly load the lifeboats
to their full rated capacities and to properly man said boats,
and to properly instruct and order those placed in command

The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)

38
 of the lifeboats to return to the ship and effect the rescue of
as many people as possible.
6. The wrongful actions and inactions which may have
resulted in the possible involuntary manslaughter by certain
officers responsible for the loading of the ship’s lifeboats.
These boats were loaded in such a manner as to negligently
and grossly under-utilize the rated capacities of the
lifeboats, directly resulting in the known deaths of at least
419 persons, in total, who might otherwise have been
accommodated in the boats and saved. Recommend that
this Final Board turn over such evidence as may exist to the
United States Attorney for review, further investigation and
consideration of sufficiency to bring criminal charges if
deemed warranted.
7. That allegations have been made by witnesses of an
instance in which one officer in charge of a lifeboat refused
to return to the scene and rescue those struggling for their
lives in the water. That such evidence as may exist in
regard to these allegations be turned over to the United
States Attorney for further investigation and prosecution if
warranted for 25 to 29 counts of voluntary manslaughter.
8. That certain allegations having been suggested by
witnesses that two passengers on board a boat carrying only
12 persons in total but capable of holding at least 40
persons unduly influenced the crew to not return to the
scene of the disaster to rescue persons in the sea, both seen
and heard to be in distress for their lives. Further it was
alleged that one of these passengers willfully and
wrongfully influenced through the issuance of promised
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
39
cash if the crew were to not return to rescue survivors for
fear of being swamped. Further that such promises to the
crew were actually paid by checks once aboard the rescue
ship Carpathia. That such evidence as may exist be turned
over to the United States Attorney for further investigation
and, if warranted, prosecution for 28 counts of voluntary
manslaughter.
Epilogue
Five days had passed since the Titanic went down with such
horrific loss of life. Every newspaper in the world carried the
story for days, some for weeks. Transatlantic passengers were
worried and nervous, and talk among both passengers and crew
on liners great and small centered around the recent Titanic
disaster.
The German liner SS Bremen passed near the position
where the Titanic foundered on what was reported to be a
bright and sunny afternoon on Saturday, 20 April 1912.
Passengers observed an enormous iceberg, the sun brilliantly
reflecting off its glistening surfaces, and some took pictures.
Word had spread on the ship and nearly everyone was out on
deck to see this sight: Was this the iceberg that sank the
Titanic?
The scene, however, quickly turned macabre as the
passengers lining the rails soon saw what appeared to be a
large number of little white dots floating in the water, some in
clusters, others alone. As the Bremen steamed closer, the
passengers could make out that the dots were in fact hundreds
of lifeless, marble-like, pale bodies still floating, rigidly upright
in their white, cork life jackets, bobbing up and down on the Nobody was
surface of the sea. It was not only possible for Bremen’s ever held responsible
passengers to clearly see what the corpses were wearing but for the deaths of over
also their faces and make out whether the bodies were male or 1,500 people. No one
female. It was a heart-rending experience. One such body spoke of justice for
clearly seen from the Bremen was that of a young woman the little white dots.
dressed in a night gown, still clutching an infant tightly against Who will speak for
her breast. Another woman appeared fully dressed with her them?
arms clinging tightly around what appeared to be the rigid and
matted body of a shaggy dog, looking much like a St. Bernard.
Dozens more bodies passed by for what were several minutes
but must have seemed like hours. The ship passed groups of
bodies, one with a cluster of three men still grasping solidly to
a deck chair, and scores of other aimlessly drifting in the open
sea. Many, many more little white dots bobbed up and down.
The silent passengers and crew of the Titanic had greeted them.
No charges were ever brought against any of the
officers or crew of the Titanic as a result of the American or
British inquiries. No officers or crew were ever charged with
negligence or brought to any adjudicatory proceeding with
respect to their certificates or seamen’s papers for their actions
or inactions preceding, during or after the disaster. No officers,
crew or passengers were ever charged with any criminal act.
Titanic’s owners were never issued administrative or civil
fines, with the exception of some civil court actions, most of
which were unsuccessful. Insurer Lloyd’s of London paid the
full amount on its policy to the White Star Line for the loss of
the Titanic.

The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)

40
Endnotes
1. This Latin legal doctrine is translated as “the cause of a
cause is the cause of the thing caused.”
2. Thomas Andrews, Jr. (1873–1912) was born in Comber a
village situated on the outskirts of Belfast. Thomas
Andrews was the nephew of Lord William Pirrie of
Harland & Wolff. He quickly rose through the ranks to
become a member of the Board. He headed the design
department and was held in great esteem by Lord Pirrie,
who was considered to be preparing Andrews as his
successor to head Harland & Wolff. He was last observed
in Titanic’s First Class smoking room staring at a painting
on the wall. Lord Pirrie had purchased all the shares of G.
W. Wolff when he retired and virtually controlled Harland
& Wolff.
3. The Official Certificate of Transcript to the Registrar
General shows the admeasurement dimensions of Titanic
and documents its length as 852 feet, 6 inches. It is
presumed the difference is due to admeasurement rules of
the time and that the 882-foot, 6-inch length was the actual
length between perpendiculars.
4. GRT or Gross Registered Tonnage is a measure of the
volumetric capacity of the ship computed under certain
rules in the admeasurement process.
5. Displacement Tonnage is the weight of sea water
displaced by a floating object. It is equal to the weight of
the object.
6. The Parson’s Steam Turbine of the time had no astern
element or no way to operate in reverse, it could only turn
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
41
the propeller shaft in a forward direction or stop with the
throttle closed.
7. The fourth stack (or British Funnel) aft, did not contain
uptakes from the boilers. It housed ventilation equipment
and galley exhaust systems.
8. The actual number of persons onboard is subject to great
controversy even today as various clearance documents
tend to be contradictory and do not reflect persons onboard
who were neither passengers nor crew. This includes 5 mail
clerks (2 employees of the U.S. Post Office and 3 of the
Royal Mail), 8 band members, 2 Marconi operators, 3
Harland & Wolff personnel, and 1 stow-away). The number
of POB’s is believed to be between 2,207 and 2,223.
9. The Mauretania and Lusitania were much faster ships than
Olympic and Titanic. These Cunard Line ships could
operate at speeds up to 27 knots and were powered by four
direct drive steam turbines, producing 68,000 horsepower
compared to Titanic’s 46,000 horsepower. Neither Titanic
nor Olympic could have set any speed records against the
two Cunard liners. Lusitania held the Blue Ribband in 1907
and 1908 and the Mauretania had held the Blue Ribband
since 1909. The myth of the Titanic being out to break a
speed record for a transatlantic crossing is a Hollywood
fabrication.
10. The Marconi iperators were employed by The Marconi
Wireless Telegraph Company, Ltd., and were not part of
the ship's crew. Marconi was a vendor to the White Star
Line, providing radio equipment and operators as well as
access to a large network of shore stations.
11. There is substantial evidence to indicate that access to the
boat deck for Third Class passengers was in fact impeded
by crew and locked gates, notwithstanding assertions to the
contrary. The latest evidence appears in the The Titanic
Commutator, the Official Journal of the Titanic Historical
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Society, Inc. Volume 37 Number 197, 2012, an excellent
publication in which Third Class passenger Katie Gilnaugh
Manning describes in correspondence her impeded passage
from Third Class to Second Class decks due to locked gates
and then again locked gates from Second Class to First
Class where she obtained help in climbing on the shoulders
of a Second Class passenger to reach the deck railing above
in the First Class decks and thence to the lifeboats. This
was related in correspondence to Mr. Edward S. Kamuda of
The Titanic Historical Society as the result of research he
conducted with Titanic survivors.
12. Manslaughter is the unlawful killing of another human
being without malice. Voluntary – upon a sudden quarrel or
heat of passion. Involuntary – in the commission of an
unlawful act not amounting to a felony, or in the
commission in an unlawful manner, or without due caution
and circumspection, of a lawful act which might prejudice
death. (b) Within the special maritime and territorial
jurisdiction of the United States: Whoever is guilty of
voluntary manslaughter shall be imprisoned not more than
ten years; whoever is guilty of involuntary manslaughter,
shall be fined not more than $1,000 or imprisoned not more
than three years, or both. This is from a 25 June 1948
statute that was the oldest I was able to locate. It is
The Final Board of Inquiry – Commander Richard R. Paton, USCGR (Ret)
42
believed, however, that the definition of the crimes as
written here would still hold true to their earlier definitions.
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